Health Problems and Correlates of Pain in Nursing Home Residents With Advanced Dementia

Abstract

This study describes the health problems and comorbid illnesses of nursing home (NH) residents with advanced dementia (n=123) and identifies correlates of staff-identified pain. Study participants were residents of 3 NHs in Maryland, their surrogate decision makers and their physicians. Residents' cognitive function was assessed at study enrollment, and their medical records were reviewed to identify all health problems/illnesses and use of pain medications during the 6 months before their enrollment. The most prevalent health problems were skin problems (95%), nutrition/hydration problems (85%), psychiatric/behavioral problems (85%), gastrointestinal problems (81%), and infections (80%). Sixty-three percent of residents had recognized pain, and 95% of those residents received pain medications. In a multivariate regression analysis, staff-identified pain was associated with aspiration (P=0.008), peripheral vascular disease (P=0.021), musculoskeletal disorders (P=0.032), higher cognitive function (P=0.013), and use of pain medications, including non-opiates (P=0.004) and the combination of opiates and non-opiates (P=0.001). NH residents with advanced dementia experience a complex mixture of multiple chronic and acute comorbidities. These results suggest the need for clinicians in long-term care facilities to be vigilant in assessing and treating pain, particularly as cognitive function declines in those with advanced dementia.

The Clinical Course of Advanced Dementia

“…Our study extends prior work describing discomfort in advanced dementia, [3][4][5]8,12,[27][28][29] showing that as the end of life approaches, there is an increase in distressing symptoms, the frequency and pattern of which are similar to those in patients with terminal cancer. 30 Moreover, patients with dementia who are dying often receive aggressive treatments, such as tube feeding or hospitalization for pneumonia, that may be of limited benefit and that are inconsistent with a palliative approach to care.…”

“…For example, prior work suggests that pain is underdocumented by nurses, particularly in patients with dementia. 8 Third, we can report only the associations between the health care proxies' perceptions of prognosis and of the complications expected and the use or nonuse of aggressive interventions -we cannot draw conclusions about cause and effect. Finally, even though all nursing home residents were put through a rigorous process of examination to determine whether they met the criteria for advanced dementia, it was not feasible to determine the time at which they first met these criteria.…”

“…Our current understanding of end-stage dementia is based on findings from retrospective studies, [3][4][5][6][7] cross-sectional studies, 8 or investigations of hospitalized patients. [9][10][11][12] The clinical course of advanced dementia has not been described in a rigorous, prospective manner.…”

Dying with Dementia: What We Know after More than a Decade of Research

“…The results of selected studies have been integrated in a recent review, showing considerable unmet needs in families [85]. Through the beginning of 2010 (Box 1, Table 1), at least 45 studies [28,[33][34][35][36][37][38][40][41][42][43]46,47,52,60,61,63,65,66,80,[86][87][88][89][90][91][92][93][94][95][96][97][98][99]110] in another 26 publications [39,44,45,53,54,64,67,69,[111][112][113][114][115]…”

“…Prospective observational [60,89,91,95,102,106,108] and intervention studies [33,86,87,101,103,104,110] provide the best evidence on how to improve care and 14 have been completed or are ongoing (Table 1). However, most studies have been small, retrospective, or both.…”